Provider Demographics
NPI:1548318983
Name:MEYER, AUDREY R (PA-C)
Entity type:Individual
Prefix:MS
First Name:AUDREY
Middle Name:R
Last Name:MEYER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:130 LINCOLN PLACE CT
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62221-5884
Mailing Address - Country:US
Mailing Address - Phone:618-257-2029
Mailing Address - Fax:618-235-5371
Practice Address - Street 1:130 LINCOLN PLACE CT
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62221-5884
Practice Address - Country:US
Practice Address - Phone:618-257-2029
Practice Address - Fax:618-235-5371
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.003238363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL3374057Medicare PIN